Basic Information
| Provider Information | |||||||||
| NPI: | 1922188135 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN HEALTH SYSTEM / OAKLAND GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OAKLAND PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43800 GARFIELD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862284652 | ||||||||
| FaxNumber: | 5862284520 | ||||||||
| Practice Location | |||||||||
| Address1: | 27472 SCHOENHERR RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480886688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827550 | ||||||||
| FaxNumber: | 5865827515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5862266838 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MI | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0000X | MI | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0505X | MI | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QG0300X | MI | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207R00000X | MI | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0E01235 | 01 | MI | BCBSM GROUP NUMBER | OTHER |